Monthly Archives: February 2013

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“Throughout 2009 and 2010, ABMS lobbied Congress for language in the healthcare reform bill to establish a MOC-PQRS program that would include incentive payment for MOC activities. Language was written into the Patient Protection and Affordable Care Act authorizing a MOC incentive but was subject to the rule making process of the Centers for Medicare and Medicaid Services (CMS).”

MOC began as a voluntary effort among physicians to put on post-doctoral training programs to keep physicians informed about new health care methods and technologies. There was a time when CME was done purely from an intellectual interest of physicians for medicine and knowledge. Medicine was still considered to be practiced within the boundaries of doctor-patient private solo situations where reputation and excellence were what brought patients to doctors and word of mouth and trust created the ‘market’ of medicine. Hospitals were run by doctors and boards of trustees and were not ever for profit, which was considered unethical, to profit from the suffering of others. Making money and profiting from suffering were morally wrong. Then hospitals often barely kept their doors open with charity care and write offs a normal part of doing business. No one was turned to collection agencies. No one was not given care, although since they still expected to buy their own medications and pay the bill eventually, patients had the honor of being trusted to pay their bills and most did. Back Continue reading →

See, a profession used
to have some power, the individual practicing it had discretion to make
his or her own decisions about a range of social matters. Unwanted
pregnancies were handled discretely and with trust. Terminally ill patients
care was done with the family’s wishes considered because of the personal
trust between the doctor and family of the patient. People were not
generic, but were accountable to one another, as they also lived in
the communities, raised kids together, and shared a common destiny
in their communities so all were committed to helping one another achieve
more and have more together. The doctor and patient actually knew each
other and the power of the profession was that the physician, because of
his education and depth of understanding of disease, would be the source
of their medical choices.

Of course back then physicians were also different. In an earlier letter, I
told you that when I first went into practice, the practice of sharing call
on weekends with other physicians was just being adopted. There were
many many physicians that thought that sharing call was a recipe for
patients to be improperly handled, because they could not possibly call
a prescription in for a person they had never examined or met. The idea
was considered preposterous by those who saw their practices as this
type of personal relationship. How could another doctor, with no knowledge
of a patient do anything but patch a situation together. And also that
entrusting a patient to another physician might be dangerous for their
patients. Because different physicians had different attitudes about
sharing call. If the physician was conscientious, he would carefully ask
all the appropriate questions and take extra time with the other doctors’
patients. But in the real world, the opposite happened, as this made
treating a generic patient, not a real patient, a practice that was
accepted as ‘community standard’ in that most physicians quickly
joined call groups, the forerunner to other types of practice associations
that led to large medical groups, instead of independent physicians.
Back then, the groups were looked down on by the real personal
physicians, as delivering a more generic form of care, with a patient
seeing a different doctor each time, and giving up entirely on the
idea of a personal relationship. Malpractice insurance soared, as
poor practices and outcomes resulted. But this only made doctors
and patients formally distrust one another, and an adversarial element
of suspicion and distrust followed. Patients did not trust these generic
decisions, and doctors did not trust patients who would sue them
for errors that resulted partly from the breakdown of communication
and personal commitment of the doctor for his patient and partly
from the compromise of quality of care that genericization caused.

I remember one of the very first weekends I shared call with some
physicians in my family practice years. As I said, just because I
took the responsibility seriously did not mean that other doctors
would. I had a patient develop chest pain after helping his brother
pick up a boat. His complaint was that his heart raced really
badly when he tried to lay down, but he felt ok as long as he
was sitting up. The on call family doctor had office hours on
Saturday when on call, which was our agreement for the group,
and he did ‘see’ the patient that Saturday. But, he did not listen
to his heart, although to the patient, that was what was worrying
him about how he was feeling, and he got a prescription for
Tagamet and was told to call me that Monday, which he did. I
saw him right away. He was a stoic 245 lb 5’11” husband of
one of my other patients. When I had him lie supine, his pulse
went up to 135 and he developed a Grade 4 systolic murmur.
I sent him straight to the ER where a cardiologist I knew well
and had called, saw him 20 minutes later. He had a papillary
muscle that was ischemic. He had a bypass the next day
and by Wednesday, he was recovering. But I was still upset
with the call-share physician, who had treated my patient like
he was a nuisance, and who had not done a proper exam and
who had put him on the Tagamet to say he did something,
but who really had done a very sloppy type of medicine and
was hiding in the gray zone of ‘no one could have known’ to
explain why he did not even examine my patient properly
and showed such attitude in a situation where medical
judgment should have nothing to do with whose patient it was
and the choice of care chosen, hospitalization hassle versus
let me do it if he has to go in next week. Not my job…..not
my patient. See? Generic patients are objects, not people
and friends, and this divorce of caring about the patient began
to become the norm. This not caring what happens to them
next in the system as long as we have done enough to not
get sued, instead of commitment to do your best for your patients.
But with that also came a breakdown of trust of doctors in
general, and the discretionary elements became defined as
abortion clinics replaced discrete solutions, urgent cares
replaced doctors always being available to their patients, and
the profession of ‘being a doctor and being who you are 24/7
was replaced by being a doctor only when you are on call, and
being allowed to become anonymous and physician duty free
part of the time. So as physicians entered with this ‘job’
mindset instead of a ‘I am who I am and I am me 24/7 and
only I can take care of MY patients, quality of care and practice
suffered and the beginning of this erosion of the actual doctor
patient relationship began.

With these people now having intruded upon our power and relationship
via more and more depersonalization and disempowerment of the
people who are actually living through the experiences, no wonder
we are all confused. These barriers between us have become
a maze where once only open trust and real human interaction
were found. But that kernel of the relationship remains, and in
some of us, that personal commitment of an educated human
being helping another trusting each other in the process has
been replaced with a role game with rules and penalties and
distrust all directions, where there was once transparency
and trust and professionalism and commitment to one another.

This is the loss that we are all lamenting, because if we are
forced to snitch on our patients and remove their rights under
the Constitution in the process, not only have our rights been
taken, but we have become the systems pawns, and we
have lost all resemblance to a true profession, whose
strength WAS the trust of patients and doctors. Without
that, medicine becomes a hollow maze of choices, none
designed or chosen by the patients, but beautifully formatted
like a good fast food menu.